methodological questions in childhood gender identity ‘desistence’ research
DESCRIPTION
A presentation to the 23rd World Professional Association for Transgender Health Biennial Symposium, Feb. 16, 2014, Bangkok, Thailand, by Kelley Winters, Ph.D., of GID Reform Advocates. It is frequently repeated in mental health literature and popular media that the vast majority of children whose gender identity differs from their assigned birth-sex, or who are severely distressed by their birth-sex, will "desist" in their gender identities and gender dysphoria by adolescence. As a consequence, gender dysphoric children are pressed to remain in their birth-assigned roles throughout the world. But are gender dysphoria and diverse gender identities just a phase? This presentation reexamines research in Canada and The Netherlands that underlies the "desistence" axiom, with respect to methodological rigor and validity of claims. Conclusions: (1) Evidence from these studies suggests that the majority of gender nonconforming children are not gender dysphoric adolescents or adults. (2) It does not support the stereotype that most children who are actually gender dysphoric will "desist" in their gender identities before adolescence. (3) These studies do acknowledge that intense anatomic dysphoria in childhood may be associated with persistent gender dysphoria and persistent gender identity through adolescence. (4) Speculation that allowing childhood social transition traps cisgender youth in roles that are incongruent with their identities is not supported by evidence. (5) These studies fail to examine the diagnostic value of Real Life Experience in congruent gender roles for gender dysphoric children.TRANSCRIPT
Kelley Winters, Ph.D.Kelley Winters, Ph.D.GID Reform AdvocatesGID Reform Advocates
The 23rd WPATH Biennial SymposiumThe 23rd WPATH Biennial SymposiumFeb. 16, 2013Feb. 16, 2013
from Loveland, Colorado, USAfrom Loveland, Colorado, USA
(Ver. E, expanded)(Ver. E, expanded) Photo by Kelley Winters Images PhotographyPhoto by Kelley Winters Images Photography
Methodological Questions in Methodological Questions in Childhood Gender Identity Childhood Gender Identity
‘Desistence’ Research‘Desistence’ Research
©2014 Kelley Winters, www.gidreform.org
How pervasive is this axiom about childhood gender dysphoria?
WhatAre
ItsConsequences?
dysphoria
persiste
d into
adulthood for o
nly
623% of child
ren.
2
“[Gender] dysphoria persisted into adulthood for only 623% of children.
...Newer studies, also including girls, showed a 12 27% persistence rate of gender dysphoria into adulthood”
(p. 11, 2011)
“Desistence” in the WPATH Standards of Care, Version 7
3Logo ©2014 WPATH
“In most children, gender dysphoria will disappear before or early in puberty.”
(p. 12, 2011)
“Desistence” in the WPATH Standards of Care, Version 7
4Logo ©2014 WPATH
“Desistence” in the DSM-5
5
“the majority [of children with GID] will become comfortable with their natal gender over time (a phenomenon termed desistence)”
(Byne, et al., 2012)
“Desistence” in the APA Task Force Report on Treatment of GID.
6Logo ©2014 WPATH
“Actually, no one knows whether Coy [Mathis] will continue to feel that she is a girl when her body develops further, since most children like her grow up to be gay, not transgender.”
(Drescher, New York Times,
2013)
“Desistence” in the Press
7
“What to do if your child is genderconfused. Next, on Dr. Phil"
(McGraw, CBS TV, 2008)
Consequent Defamation of “Confusion”
8
“very few children who demonstrate gender confused behavior continue to do so in their later teen years or early adulthood”
(Stanton, focusonthefamily.com,2009)
“Confusion” in Religious Extremism
9
“[California] AB 1266 aims to require all public schools to allow gender confused youth to use facilities,... based solely on their perceived 'gender identity' and not their biological sex.”
(Pacific Justice Institute, 2013)
“Confusion” in Political Extremism
10
dysphoria
persiste
d
into adulthood for
only 623% of
children
.
Given the stakes,
Is thisassumptionactuallytrue?
Science ?Opinion?
Meme?Dogma?
11
A Point of Science:
“the burden of proof in science rests invariably on the individuals making a claim, not on the critic.”
Lilienfeld, Lynn and Lorh, Science and Pseudoscience in Clinical Psychology, 2004
12
Drummond, K. D.; Bradley, S. J.; Peterson-Badali, M.; Zucker, K. J. (2008)
Wallien, M.S.C. & Cohen-Kettenis, P.T. (2008)
Steensma, T.D.; Biemond, R.; de Boer, F. & Cohen-Kettenis, P.T. (2011)
Three Key Cited Studies from Toronto and the Netherlands:
13
Concern 1: Fallacy of Conflated Subsets
Are Socially Transitioned Kids, Gender Are Socially Transitioned Kids, Gender Dysphoric Kids, Kids Dx with “GID,” Dysphoric Kids, Kids Dx with “GID,”
and Nonconforming Kids and Nonconforming Kids synonymous?synonymous?
14
Conflated Subsets
“Children diagnosed with gender identity disorder (GID) have a strong crossgender identification and a persistent discomfort with their biological sex or gender role associated with that sex (gender dysphoria)”
(Wallien, et al. 2008)
15
Conflated Subsets
16
In truth, In truth, Socially Transitioned KidsSocially Transitioned Kids are a tiny subset of--are a tiny subset of--Gender Dysphoric Kids Gender Dysphoric Kids are a subset of--are a subset of-- Kids Dx with GIDC/GDCKids Dx with GIDC/GDC are a small subset of--are a small subset of-- Gender Nonconforming KidsGender Nonconforming Kids
Concern 2: Sample Bias in DSM Intake Criteria
“it is conceivable that the childhood criteria for GID may “scoop in” girls who are at relatively low risk for adolescent/adult genderdysphoria that revolves so much around somatic indicators...”
(Drummond, et al., 2008)
17
Concern 3: Results Skewed by Treatment
“It is beyond the scope of this report to describe the types of therapies ... received between the assessment in childhood and followup...
13 of the 25 girls had at least some contactwith our clinic ...”
(Drummond, et al., 2008)
18
Concern 4: Omitted Long Term Followup
“the median age at which trans people first visited their GP to discuss their gender dysphoria has been rising and is currently 42.”
(Reed, et al., 2009)
19
Concern 5: Dismissed Retrospective Evidence
“Age of epiphany... clear spike at age 5 years, representing the modal average, with a mean average of 7.9 years. ”
(Kennedy, et al., 2012)20
Concern 6: Unfounded Assumptions
“...(45.3%) did not reapply for
treatment at the Gender Identity
Clinic during adolescence... we
assumed that their gender dysphoric
feelings had desisted...”(Steensma, et al., 2011)
21
Concern 7: Magic Sticky Flypaper Theory
“[Parents/Caregivers] may help the child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse. ”
(Steensma, et al., 2011)22
The Magic Sticky Flypaper Theory
23
The Steensma paper The Steensma paper speculatively disparaged speculatively disparaged childhood social transition, childhood social transition, without studying gender without studying gender dysphoric children who dysphoric children who actually transitioned actually transitioned socially.socially.
Concern 8: The 800 lb. Taboo Question
Does Real Life Experience in congruent roles (including nonbinary roles) have similar diagnostic value for children as in adults and adolescents?
24
A Closer Look at Drummond, et al., 2008
The Claim-- 88% “desistence” of 25 “girls” with full or sub-threshold childhood GID after age 17.
A Clarification-- 59% of a cohort of 37 nonconforming birth-assigned girls reported female identity after age 17; 8% transitioned medically; 32% unknown; none were followed long term.
25
A Closer Look at Wallien, et al., 2008
The Claim-- “27% of our total group of gender-dysphoric children was still gender dysphoric in adolescence.”
A Clarification-- 27% of 77 gender nonconforming children transitioned medically after age 16; less than half, 43%, identified with birth-assignment; 30% unknown; none followed long term.
26
A Closer Look at Steensma, et al., 2011
The Claim-- 55% of 53 children meeting GIC criteria sought medical transition in adolescence; nonrespondents, 45%, “desisted” in gender dysphoria.
A Clarification—More than half, 55%, of 77 children meeting GID criteria sought medical transition in adolescence; 45% were unknown.
27
Speaking of Steensma, et al., 2011
The Claim-- “These accounts imply that the presence of body discomfort may contribute significantly to persistence or desistence of childhood gender dysphoria .”
-- This key finding, persistence of early anatomic dysphoria, has been ignored in much of the literature and press. 28
Summary
(1) Evidence from these studies suggests that the majority of gender nonconforming children are not gender dysphoric adolescents or adults.
(2) It does not support the stereotypethat most children who are actually gender dysphoric will "desist" in their gender identities before adolescence.
29
Summary
(3) These studies do acknowledge that intense anatomic dysphoria in childhood may be associated with persistent gender dysphoria and persistent gender identity through adolescence.
30
Summary
(4) Speculation that allowing childhood social transition traps cisgender youth in roles that are incongruent with their identities is not supported by evidence.
(5) These studies fail to examine the diagnostic value of Real Life Experience in congruent gender roles for gender dysphoric children.
31
ReferencesAmerican Psychiatric Association (2014). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.
Byne, W., Bradley, S.J., Coleman, E., Eyler, A.E., Green, R., Menvielle, E.J., Meyer-Bahlburg, H.F.L., Pleak, R.R. & Tompkins, D.A. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41(4):759-796.
Drescher, J. (2013) "Sunday Dialogue: Our Notions of Gender," New York Times, June 29, http://www.nytimes.com/2013/06/30/opinion/sunday/sunday-dialogue-our-notions-of-gender.html
Drummond, Kelley D.; Bradley, Susan J.; Peterson-Badali, Michele; Zucker, Kenneth J. (2008), "A follow-up study of girls with gender identity disorder," Developmental Psychology. Vol 44(1), Jan 2008, 34-45.
Kennedy, N. (2012) "Transgender children: more than a theoretical challenge," Goldsmiths College, University of London, http://academia.edu/2760086/
Reed, B., Rhodes, S., Schofield, P., Wylie, K., (2009) "Gender variance in the UK. Prevalence, incidence, growth and geographic distribution," GIRES – the Gender Identity Research and Education Society, http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf
Steensma, T.D., Biemond, R., de Boer, F. & Cohen-Kettenis, P.T. (2011). Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology & Psychiatry, 16(4):499-516.
Wallien, M.S.C. & Cohen-Kettenis, P.T. (2008). Psychosexual outcome of gender-dysphoric children. J American Academy Child & Adolescent Psychiatry, 47:1413-1423.
Winters, K. (2013) Response to Dr. Jack Drescher and the NY Times About Childhood Transition, GID Reform Weblog, July 5, http://gidreform.wordpress.com/category/childhood-social-transition/
World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Author.
32
Kelley Winters, Ph.D.Kelley Winters, Ph.D.GID Reform AdvocatesGID Reform Advocates
The 23rd WPATH Biennial SymposiumThe 23rd WPATH Biennial SymposiumFeb. 16, 2013Feb. 16, 2013
from Loveland, Colorado, USAfrom Loveland, Colorado, USA
(Ver. E, expanded)(Ver. E, expanded) Photo by Kelley Winters Images PhotographyPhoto by Kelley Winters Images Photography
Methodological Questions in Methodological Questions in Childhood Gender Identity Childhood Gender Identity
‘Desistence’ Research‘Desistence’ Research
©2014 Kelley Winters, www.gidreform.org